Orthopedic Footwear

Affected Providers

Treating practitioners and DME suppliers who bill for orthopedic footwear.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Orthopedic Footwear (L33641) and Article: Orthopedic Footwear (A52481) have the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for orthopedic footwear is 0%, with a projected improper payment amount of $0.

According to the 2023 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for orthopedic footwear was 100%, with a projected improper payment amount of $4.3 million.

Denial Reasons

No denial reasons were listed in the 2024 Comprehensive Error Rate Testing report for orthopedic footwear. Insufficient documentation accounted for 84.5% of improper payments for orthopedic footwear during the 2023 reporting period, while no documentation (9.3%), medical necessity (0.9%), and other errors (5.3%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

Orthopedic footwear is covered under the leg, arm, back, and neck braces, and artificial legs, arms, and eyes benefit if they’re an integral part of a covered leg brace.

Find specific documentation requirements for orthopedic footwear in LCD L33641 and Article A52481.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.

Example of Improper Payments Due to Insufficient Documentation for Orthopedic Footwear

A supplier bills the claim for HCPCS code L1900 (Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom fabricated) and submits the following documentation per the review contractor’s request:

• Standard written order with correct HCPCS coding
• Treating practitioner’s medical record that has sufficient medical necessity documentation

What Documentation Was Missing?

There was no proof of delivery in the submitted documentation.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the Medicare Administrative Contractor recoups payment.

Recommendation

To prevent claim denials and improper payments, the certifying physician must collect and submit proper documentation, including proof of delivery, in the treating practitioner’s medical record for DMEPOS.